Did doctors neglect signs of torture in Guantanamo?

Salus aegroti suprema lex is Latin for the ‘wellbeing of the patient is the most important law’.

Beneficence is a core value of medical ethics that may have been compromised by health care personnel that failed to inquire about or document causes of injuries and psychological symptoms they observed in Guantanamo Bay (GTMO), according to a paper published this week in PLoS Medicine.

After the September 11th attacks, the US government authorized use of ‘enhanced interrogation techniques’ (EIT), including waterboarding, forced nudity, sleep deprivation, temperature extremes, and stress positions. Evidence of these practices and other ill treatment of detainees in GTMO was revealed via inspection of medical records, case files, and legal affidavits by non-governmental experts, led by Vincent Iacopino, Senior Medical Advisor for Physician for Human Rights, and Brigadier General (Ret) Stephen Xenakis, U.S. Army. Their study of 9 cases of male detainees from GTMO included the following allegations:

In addition to the use of authorized EITs, each of the nine detainees reported being subjected to ‘unauthorized’ acts or torture including: severe beatings, often associated with loss of consciousness and/or bone fractures, sexual assault and/or the threat of rape, mock execution, mock disappearance, and near asphyxiation from water (i.e., hose forced into the detainee’s mouth) or being choked. Other allegations included forcing the detainee’s head into the toilet, being used as a human sponge to wipe the floor…

The authors write that the GTMO medical records do not mention the causes of physical injuries that are consistent with detainee allegations of abuse in 3 cases: “contusions (2), bone fractures (3), lacerations (2), peripheral nerve damage (1), and sciatica (2).” Another detainee alleged that he saw an interrogator with his medical records and that his “chronic back pain was exploited by interrogators through prolonged, painful stress positions.”

According to the study, GTMO medical records indicate that none of the detainees had a past psychological history, prior to detainment at GTMO, but 8 of 9 cases were later documented as having significant psychological symptoms, including nightmares (5), suicidal ideation (4), audiovisual hallucinations (3), suicide attempts (2); and Department of Defense mental health providers with the Behavioral Health Service (BHS) evaluated 6 of 9 detainees and made the following diagnoses: “depression (4), passive aggressive personality (4), borderline personality (2), adjustment disorder (3), routine stressors of confinement (2), narcissistic traits (1), psychosis or depression with psychotic features (2), and anxiety NOS (not otherwise specified) (2).”

The authors wrote about BHS notes describing 7 detainees having symptoms supporting a diagnosis of PTSD, but “BHS clinicians did not indicate inquiring about or documenting possible causes of these symptoms and/or the diagnosis of PTSD.”

One of the limitations of this study is that the cases reviewed were those for which the authors were consulted, increasing the possibility of selection bias. The psychological assessments are potentially subject to bias from both the detainee and interviewer. The results from 9 cases may not be generalizable to other GTMO detainees, but there are other reports documenting US endorsement of harsh interrogation techniques.

The United Nations Convention Against Torture has prohibited torture and previously recognized waterboarding, sleep deprivation, and prolonged isolation, as torture. Nations participating in the Geneva Convention agreed not to torture prisoners, but after 9/11, the US government redefined some of these practices as EITs and approved their use, putting health care providers working in detention camps like GTMO in potentially compromising situations.

Health care professionals have been complicit with the design and monitoring of EITs, as called for in the memos that authorized their use. It was not until 2005 that Department of Defense providers mentioned a duty to document abuse. In 2007, The New York Timesreported that President Bush signed an order allowing the CIA to resume the use of harsh interrogation methods.

In one of his first acts of office, President Obama ordered that no one from the US government could rely upon any interpretation of the law governing interrogation issued by the Department of Justice between September 11th 2001 and January 20, 2009. In April of 2009, the President allowed the release of interrogation memos and issued a statement from the White House that was published in the New York Times:

In releasing these memos, it is our intention to assure those who carrying out their duties relying in good faith upon the legal advice from the Department of Justice that they will not be subject to prosecution.

It seems only fair that this statement should apply to similarly involved physicians and mental health workers, but raises the question of whether health care personnel are bound to the ethics of their profession or federal duty. These 9 cases illustrate a situation where it was hard to do both.

UPDATE: An organization called the Center for Justice & Accountability (CJA) is taking a step forward in attempting to hold health care professionals accountable for their roles in Guantanamo.

Kathy Roberts is a UC Berkeley Law School graduate and lead attorney for a professional misconduct complaint filed by the CJA against a psychologist alleged to have had a role in abusive interrogation at Guantanamo. She told me that no U.S. official involved, including health care professionals, has ever been held accountable for the cruel treatment of detainees at Guantanamo. She shared some details:

The Center for Justice & Accountability and the New York Civil Liberties Union represent New York psychologist Dr. Steven Reisner in this proceeding against the New York Department of Education’s Office of Professional Discipline (OPD) for its failure to investigate his fellow New York psychologist Dr. John Leso for his role in the abusive interrogation program at Guantanamo Bay, Cuba.

Dr. Reisner and CJA filed a professional misconduct complaint against Dr. Leso last July, alleging that while Dr. Leso served as a clinical psychologist at Guantanamo, he recommended a series of escalating physically and psychologically abusive interrogation tactics to be used on detainees and personally supervised and participated in interrogations where his tactics were used. The OPD declined jurisdiction, claiming that Dr. Leso’s alleged conduct at Guantanamo did not qualify as the practice of psychology as defined by New York law.